Provider Demographics
NPI:1578747101
Name:ISLAND CHIROPRACTIC AND ACUPUNCTURE CLINIC LLC
Entity Type:Organization
Organization Name:ISLAND CHIROPRACTIC AND ACUPUNCTURE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LASKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:956-761-6006
Mailing Address - Street 1:3311 PADRE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOUTH PADRE ISLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78597-7048
Mailing Address - Country:US
Mailing Address - Phone:956-761-6006
Mailing Address - Fax:956-761-6002
Practice Address - Street 1:3311 PADRE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTH PADRE ISLAND
Practice Address - State:TX
Practice Address - Zip Code:78597-7048
Practice Address - Country:US
Practice Address - Phone:956-761-6006
Practice Address - Fax:956-761-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8835111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX606681OtherBLUE CROSS BLUE SHIELD
TXU83288Medicare UPIN
TX606681OtherBLUE CROSS BLUE SHIELD